Ba sic Asse ssme nt: a nd Alp ha b e t so up ! Yo u c a n use fo - - PowerPoint PPT Presentation

Ba sic Asse ssme nt: a nd Alp ha b e t so up ! Yo u c a n use fo r a ll p a tie nts!

T his to p ic will re view the nurse s a sse ssme nt impo r tanc e in the a sse ssme nt o f a ll typ e s o f p a tie nts that p re se nt to E D a nd a lso c a n b e use d o n inp atients.

L e t’ s g e t Sta rte d

 Wha t d o the a c ro nyms me a n a nd d o the y he lp !!  We ll Ye s the y d o  F

• llow up e ve r

y p atie nt eve r y time a nd yo u wo n’ t miss a thing!

 L

e t’ s sta rt :

No w A,B,C, D ( sing a lo ng )

 C AND A to ge the r : Ble e d ing( c irc ulatio n Obvious b le eding) Sto p a nd

c o ntro l

 Airway a nd C sp ine : L

• o k, into the a irwa y, listen fo r no ise s, b re a thing, F

e e l fo r a ir mo vement: Inte r vene : Ho w?

 Re p o sition, Suc tio n, Ap p ly O2, Sto p a nd Ba g: Is tha t e a sy?  Ja w thrust a nd E

C T e c hnique

L e t’ s d e sc rib e the BVM

Hig h F lo w Oxyg e n T he ra p y

Ne o na ta l to Ad ult

Are we b re a thing ye t? ?

 F

• r the p a tient

 Or p a tie nt o n the ir o wn  Ho w e ffe c tive a re we o r the y  Ra te a nd d e e p o f re sp ir

a tio ns

 E

ffe c tive ne ss: Co lor improving

 Are we tiring o r is the p a tie nt tiring?

B: Bre a thing is it e ffe c tive ? ?

 Co lo r  Ale rt  Ra te a nd d e p th  Is o ur a d junc t wo rking  Ca n we mo ve o n?

C: Circ ula tio n

 Ble e d ing?  Co lo r  Ce ntra l a nd p e rip he ral p ulse s  If we a k o r d iffe re nt why?  Do we ne e d b lo o d , fluid s,Oxyge n, More c a rd iac o utput  Wha t is the p a tie nts c hie f c o mplaint?

D: Disa b ility

 Ne uro sta tus  Me ntatio n: BS  Pup ils  GCS Sc o re

E : E xp o sure a nd E nviro nme nta l Co ntro l

Ge t the pa tie nts c lo the s o ff, pla c e in g o wn All pa tie nts g e t na ke d!!! Co ve r, pro te c t mo de sty a nd q uic k a sse ss the skin

F : F ull se t o f Vita l Sig ns

 T

his inc lude s T e mpe ra ture

 He a rt ra te  Re spira to ry ra te  Blo o d pre ssure :  Ho w to ta ke b lo o d pre ssure : T

his is whe n I a usc ulta te o ne if the pa tie nt is sic k”

G: Give c o mfo rt me a sure a nd Ge t Mo nito ring d e vic e s

 Co mfo rt: Pa in, No n p ha rma c o logic al mea sure s  Pa in me d ic a tio ns  All mo nitors o n, re a sse ss Vital signs  Blo o d suga r  L

: IV,labsif no t d o ne

 M: Mo nito r  Oxyge na tio n: Re a sse ss, Sa tura tio n wo rk o f b re a thing, Ca p no gra phy? Do

we ne e d it?

 De p e nd s o n p a tie nt

H: Histo ry

 Why a re the he re  Wha t is c hie f c o mp laint to d a y  Is it re la te d to p rio r Histo r

y: T ha nks to e le c tro nic he alth re c ords we c a n usua lly find so me info rma tion

 F

ind ings to c a use a la rm: Ale rt p rovide r

 Me dic atio ns: Have the y b e e n ta king the m a nd if so whe n,wha t a nd ho w

muc h

 Dia gno stic s : Wha t d o yo u a ntic ipa te will b e ne e d e d ?  He lp yo ur p ro vid er o ut a s yo u se e the p a tie nt first a nd la st in mo st c a se s.

Insp e c t a nd re a sse ss

 He a d to to e a sse ssme nt a nd d o n’ t fo rge t the b a c k sid e  We might no tic e skin c olo r c ha nge s, sta rt o f d e c ub iti's ulc e r, unke mpt

hygie ne

With e a c h p a tie nt e a c h time We will ha ve g o o d o ut c o me s

 Dilige nt b y b e d sid e c are give rs save s p a tients a nd ho p e fully p reve nts

d e c line .

Re fe re nc e s

 E

NA.o rg

 Ame ric a n Assoc iatio n o f Critic al c a re : AACN.o rg  E

M ra p